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Murro V, Banfi S, Testa F, Iarossi G, Falsini B, Sodi A, Signorini S, Iolascon A, Russo R, Mucciolo DP, Caputo R, Bacci GM, Bargiacchi S, Turco S, Fortini S, Simonelli F. A multidisciplinary approach to inherited retinal dystrophies from diagnosis to initial care: a narrative review with inputs from clinical practice. Orphanet J Rare Dis 2023; 18:223. [PMID: 37525225 PMCID: PMC10388566 DOI: 10.1186/s13023-023-02798-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 07/05/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Non-syndromic inherited retinal dystrophies (IRDs) such as retinitis pigmentosa or Leber congenital amaurosis generally manifest between early childhood and late adolescence, imposing profound long-term impacts as a result of vision impairment or blindness. IRDs are highly heterogeneous, with often overlapping symptoms among different IRDs, and achieving a definite diagnosis is challenging. This narrative review provides a clinical overview of the non-syndromic generalized photoreceptor dystrophies, particularly retinitis pigmentosa and Leber congenital amaurosis. The clinical investigations and genetic testing needed to establish a diagnosis are outlined, and current management approaches are discussed, focusing on the importance of the involvement of an interdisciplinary team from diagnosis and initial care to long-term follow-up and support. RESULTS The effective management of IRDs requires a multidisciplinary, and ideally interdisciplinary, team of experts knowledgeable about IRDs, with experienced professionals from fields as diverse as ophthalmology, neuropsychiatry, psychology, neurology, genetics, orthoptics, developmental therapy, typhlology, occupational therapy, otolaryngology, and orientation and mobility specialties. Accurate clinical diagnosis encompasses a range of objective and subjective assessments as a prerequisite for the genetic testing essential in establishing an accurate diagnosis necessary for the effective management of IRDs, particularly in the era of gene therapies. Improvements in genome sequencing techniques, such as next-generation sequencing, have greatly facilitated the complex process of determining IRD-causing gene variants and establishing a molecular diagnosis. Genetic counseling is essential to help the individual and their family understand the condition, the potential risk for offspring, and the implications of a diagnosis on visual prognosis and treatment options. Psychological support for patients and caregivers is important at all stages of diagnosis, care, and rehabilitation and is an essential part of the multidisciplinary approach to managing IRDs. Effective communication throughout is essential, and the patient and caregivers' needs and expectations must be acknowledged and discussed. CONCLUSION As IRDs can present at an early age, clinicians need to be aware of the clinical signs suggesting visual impairment and follow up with multidisciplinary support for timely diagnoses to facilitate appropriate therapeutic or rehabilitation intervention to minimize vision loss.
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Affiliation(s)
- Vittoria Murro
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
- Eye Clinic, Careggi Teaching Hospital, Florence, Italy
| | - Sandro Banfi
- Telethon Institute of Genetics and Medicine (TIGEM), Pozzuoli, NA, Italy
- Medical Genetics, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Francesco Testa
- Eye Clinic, Multidisciplinary Department of Medical, Surgical and Dental Sciences, University of Campania Luigi Vanvitelli, Naples, Italy.
| | - Giancarlo Iarossi
- Department of Ophthalmology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Benedetto Falsini
- Ophthalmology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Sodi
- Eye Clinic, Careggi Teaching Hospital, Florence, Italy
| | - Sabrina Signorini
- Center of Child Neuro-Ophthalmology, IRCCS, Mondino Foundation, Pavia, Italy
| | - Achille Iolascon
- Medical Genetics Unit, Azienda Ospedaliera Universitaria Federico II, Naples, Italy
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy
- CEINGE-Biotecnologie Avanzate, Naples, Italy
| | - Roberta Russo
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Naples, Italy
- CEINGE-Biotecnologie Avanzate, Naples, Italy
| | - Dario Pasquale Mucciolo
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
- Ophthalmology Unit, San Jacopo Hospital, Pistoia, Italy
| | - Roberto Caputo
- Pediatric Ophthalmology Unit, A. Meyer Children's Hospital IRCCS, Florence, Italy
| | - Giacomo Maria Bacci
- Pediatric Ophthalmology Unit, A. Meyer Children's Hospital IRCCS, Florence, Italy
| | - Sara Bargiacchi
- Medical Genetics Unit, Ospedale Pediatrico Meyer, Florence, Italy
| | - Simona Turco
- National Centre of Services and Research for the Prevention of Blindness and Rehabilitation of the Visually Impaired, International Agency for the Prevention of Blindness-IAPB Italy Onlus, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefania Fortini
- National Centre of Services and Research for the Prevention of Blindness and Rehabilitation of the Visually Impaired, International Agency for the Prevention of Blindness-IAPB Italy Onlus, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Simonelli
- Eye Clinic, Multidisciplinary Department of Medical, Surgical and Dental Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
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Birtel J, von Landenberg C, Gliem M, Gliem C, Reimann J, Kunz WS, Herrmann P, Betz C, Caswell R, Nesbitt V, Kornblum C, Issa PC. Mitochondrial Retinopathy. Ophthalmol Retina 2021; 6:65-79. [PMID: 34257060 DOI: 10.1016/j.oret.2021.02.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE To report the retinal phenotype and the associated genetic and systemic findings in patients with mitochondrial disease. DESIGN Retrospective case series. PARTICIPANTS Twenty-three patients with retinopathy and mitochondrial disease, including chronic progressive external ophthalmoplegia (CPEO), maternally inherited diabetes and deafness (MIDD), mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS), Kearns-Sayre syndrome, neuropathy, ataxia, and retinitis pigmentosa (NARP) syndrome, and other systemic manifestations. METHODS Review of case notes, retinal imaging, electrophysiologic assessment, molecular genetic testing including protein modeling, and histologic analysis of muscle biopsy. MAIN OUTCOME MEASURES Phenotypic characteristics of mitochondrial retinopathy. RESULTS Genetic testing identified sporadic large-scale mitochondrial DNA deletions and variants in MT-TL1, MT-ATP6, MT-TK, MT-RNR1, or RRM2B. Based on retinal imaging, 3 phenotypes could be differentiated: type 1 with mild, focal pigmentary abnormalities; type 2 characterized by multifocal white-yellowish subretinal deposits and pigment changes limited to the posterior pole; and type 3 with widespread granular pigment alterations. Advanced type 2 and 3 retinopathy presented with chorioretinal atrophy that typically started in the peripapillary and paracentral areas with foveal sparing. Two patients exhibited a different phenotype: 1 revealed an occult retinopathy, and the patient with RRM2B-associated retinopathy showed no foveal sparing, no severe peripapillary involvement, and substantial photoreceptor atrophy before loss of the retinal pigment epithelium. Two patients with type 1 disease showed additional characteristics of mild macular telangiectasia type 2. Patients with type 1 and mild type 2 or 3 disease demonstrated good visual acuity and no symptoms associated with the retinopathy. In contrast, patients with advanced type 2 or 3 disease often reported vision problems in dim light conditions, reduced visual acuity, or both. Short-wavelength autofluorescence usually revealed a distinct pattern, and near-infrared autofluorescence may be severely reduced in type 3 disease. The retinal phenotype was key to suspecting mitochondrial disease in 11 patients, whereas 12 patients were diagnosed before retinal examination. CONCLUSIONS Different types of mitochondrial retinopathy show characteristic features. Even in absence of visual symptoms, their recognition may facilitate the often challenging and delayed diagnosis of mitochondrial disease, in particular in patients with mild or nebulous multisystem disease.
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Affiliation(s)
- Johannes Birtel
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Department of Ophthalmology, University Hospital Bonn, Bonn, Germany; Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | - Christina von Landenberg
- Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany; Department of Neurology, Section of Neuromuscular Diseases, University Hospital Bonn, Bonn, Germany
| | - Martin Gliem
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Carla Gliem
- Department of Neurology, Section of Neuromuscular Diseases, University Hospital Bonn, Bonn, Germany
| | - Jens Reimann
- Department of Neurology, Section of Neuromuscular Diseases, University Hospital Bonn, Bonn, Germany
| | - Wolfram S Kunz
- Department of Epileptology, Life & Brain Center, University Hospital Bonn, Bonn, Germany
| | - Philipp Herrmann
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany; Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany
| | - Christian Betz
- Bioscientia Center for Human Genetics, Ingelheim, Germany
| | - Richard Caswell
- Genomics Laboratory, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom; Institute of Biomedical and Clinical Science, University of Exeter School of Medicine, Exeter, United Kingdom
| | - Victoria Nesbitt
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Nuffield Department of Women's & Reproductive Health, The Churchill Hospital, Oxford, United Kingdom
| | - Cornelia Kornblum
- Center for Rare Diseases Bonn (ZSEB), University Hospital Bonn, Bonn, Germany; Department of Neurology, Section of Neuromuscular Diseases, University Hospital Bonn, Bonn, Germany
| | - Peter Charbel Issa
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom.
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Abstract
PURPOSE To evaluate choroidal features in young patients affected by choroideremia (CHM). METHODS Young CHM patients and control subjects were recruited at the Eye Clinic in Florence. High-resolution choroidal imaging was obtained using swept-source optical coherence tomography with long optical coherence tomography scans (12 × 9 mm optical coherence tomography scans). We considered the subfoveal choroidal area within 9 mm of the optic disk in the horizontal plane and the subfoveal choroidal area within a 3-mm diameter centered over the fovea. The subfoveal choroidal thickness, total choroidal area, luminal area, stromal area, and choroidal vascularity index were assessed using the "ImageJ" software in both groups. RESULTS Eight patients (16 eyes; mean age, 19.3 ± 5.2 years) and seven control subjects (14 eyes; mean age, 19.0 ± 5.0 years) were included in this study. Best-corrected visual acuity was 20/20 in both eyes of seven CHM patients and in all control subjects and 20/25 in both eyes in one CHM patient. Mean subfoveal choroidal thickness did not differ between CHM patients and control subjects. Luminal area9mm, stromal area9mm, and total choroidal area9mm were reduced in patients compared with the control group. Luminal area3mm, stromal area3mm, and total choroidal area3mm did not differ between patients and control subjects. Choroidal vascularity index9mm and choroidal vascularity index3mm were not different between patients and control subjects. CONCLUSION There are no differences in the choroidal vascularity index between young CHM patients and control subjects; this result suggests a simultaneous, proportional impairment of both the stromal and vascular components of the choroid in the early stages of the disease.
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